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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005496
Report Date: 12/14/2024
Date Signed: 12/14/2024 10:50:51 AM

Document Has Been Signed on 12/14/2024 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GENTLE SENIOR CAREFACILITY NUMBER:
306005496
ADMINISTRATOR/
DIRECTOR:		MIRABUENO, MARIA PRICILLAFACILITY TYPE:
740
ADDRESS:4193 TERESA AVETELEPHONE:
(213) 446-1695
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:21 AM
MET WITH:Caregiver Melgasbal ManuelTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met Caregiver Melgasbal (Mel) Manuel at approximately 8:15 AM and explained reason for visit. Administrator Maria Mirabueno was notified by telephone.

The facility is licensed for 6 non-ambulatory residents. The facility has a Hospice waiver for 3 residents. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, kitchen, dining room, five (5) resident bedrooms, three (3) bathrooms, front yard, backyard, and attached garage.

LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguisher which is kept in kitchen. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. Bathrooms had required grab bars and nonskid mats. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

Tony VasalloTELEPHONE: (323) 981-3977
Christian GutierrezTELEPHONE: (323) 981-3984
DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GENTLE SENIOR CARE
FACILITY NUMBER: 306005496
VISIT DATE: 12/14/2024
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Three (3) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) residents files were reviewed and included physicians report, TB clearance. Last fire/earthquake drill was conducted in September of 2024. Infectious control plan will be emailed to LPA. Two (2) staff and (1) resident was interviewed. Five (5) resident medications were reviewed. Medications are centrally stored and locked MAR log is used.

No deficiency was observed during today’s visit. Exit interview was conducted with Caregiver and a copy of report was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC809 (FAS) - (06/04)
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